558
ing, and so make it difficult for the student to develop the holistic approach which he will need to adopt if he is to meet the needs of his patients and overcome the constraints of limited time which he will meet in real practice. It seems probable, therefore, that the history-taking skills of medical students could be much improved if these gaps in training were remedied. We suggest that this could be done as follows: by giving students a more detailed and relevant model of how to take an initial history and what questions to ask; by giving them a chance to practise this under conditions of direct observation within strict time-limits; and by providing them with feedback about their performance. Indeed, we have already put these suggestions to the test, and, as we report in the following paper" and in a recent review,12 the results have been encouraging. They indicate that much could be done of a practical nature to help medical students and doctors to improve their history-taking skills, particularly if such training were given at the beginning of their clinical course, or even
pre-clinically. 13I
This work was carried out while both authors were in the departof psychiatry, University of Oxford. D. R. R. was supported by the Mental Health Trust and Research Fund and by the Medical Research Council. We thank Prof. Michael Gelderfor his encouragement and the patients for their cooperation.
who received only traditional training. Results of the second experiment suggest that most of the programme’s effect is attributable to discussion of a printed handout which presents the student with a detailed scheme for taking histories. INTRODUCTION
preceding paper,’ we drew attention to a growing body of evidence which suggests that traditional methods of clinical training are failing to equip doctors with basic skills for taking patients’ histories. We have developed our own training programmes,2 and have tested its value in two experiments. The first tested the IN the
programme as a whole, and the second assessed the relative importance of its separate components. FIRST EXPERIMENT
The first experiment tested the hypothesis that the amount of relevant and accurate information reported at the end of a test interview would be greater for students trained by our programme than for those trained
by traditional methods.
ment
REFERENCES
1.
Hampton, J. R., Harris, M. J. G., Mitchell, J. R. A., Prichard, J. S., Seymour, C. Br. med. J. 1975, ii, 486. 2. Anderson, J., Day, J. L., Dowling, M. A. C., Pettingale, K. W. Post-Grad. med. J. 1970, 46, 606. 3. Tapia, F. Br. J. med. Educ. 1972, 6, 133. 4. Maguire, G. P., Clarke, D., Jolley, B., Unpublished. 5. Helfer, R. E. Pediatrics, Springfield, 1970, 45, 623. 6. MacNamara, M. Br. J. med. Educ. 1974, 8, 17. 7. Maguire, G. P., Julier, D. L., Hawton, K. E., Bancroft, J. H. J. Br. med. J. 1974, i, 286. 8. Korsch, B. M., Gozzi, E. K., Francis, V. Pediatrics, Springfield, 1968, 42, 855.
Maguire, G. P. in Modern Perspectives in Psychiatric Aspects of Surgery (edited by J. Howells and M. Bruner); New York (in the press). 10. Goldberg, D. P., Blackwell, B. Br. med. J. 1970, ii, 439. 11. Rutter, D. R., Maguire, G. P. Lancet, 1976, ii, 558. 12. Maguire, G. P., Rutter, D. R. in Communication between Doctors and Patients (edited by A. E., Bennett); p.45. Oxford, 1976. 13. British Medical Journal, 1976, i, 1362. 9.
HISTORY-TAKING FOR MEDICAL STUDENTS II—EVALUATION OF A TRAINING PROGRAMME
D. R. RUTTER
Department of Psychology, University of Warwick, Coventry CV4 7AL
Subjects and Procedure A consecutive sample of 24 medical students took part in the experiment during their first psychiatric attachment. All had already received a traditional training in taking histories. 12 were randomly allocated to a "training" group, and 12 to a "no-training" group, and each student conducted two videotaped interviews which were separated by a week. On each occasion, the student was set the task of spending 15 minutes with the patient and of finding out as much as he could about the current illness or problems. He was told that the patient was suffering from an affective disorder, that the interview would be videotaped, that it was his responsibility to terminate the interview on time, and that he would be asked to write up the patient’s history immediately afterwards. The patients-inpatients, day-patients, or outpatients-were suffering from clearly diagnosed affective disorders, and were selected by medical staff not otherwise connected with the experiment. Each student met a different patient on the two occasions, and each patient took part in only one interview. Having written up the patient’s history at the end of the first interview, students assigned to the no-training group were sent allay without comment, and were asked to return the following week for the second interview and not to discuss the experiment in the meantime. Those assigned to the training group remained and were given their training, individually, by G.P.M. One week later, all 24 students returned for their second interviews and, after they had written up the patient’s history, they were debriefed,
G. P. MAGUIRE
University Department of Psychiatry, University Hospital of South Manchester, West Didsbury, Manchester M20 8LR
Training Details of the
training
programme have been giver a printed handed
elsewhere.2 First, the student is given
sets out a standard, structured scheme for taking histories, and draws attention both to the informaticr
which Two experiments designed to evaluate a Summary programme for training medical students in history-taking skills were carried out. Results of the first indicate that students who underwent the programme reported almost three times as much relevant and accurate information after a test interview as those
which should be obtained and to the techniques v.h). should be used. He reads the handout carefully and d.i cusses it with the trainer. Next, his interview is reptaBei The recording can be stopped and replayed again at jr point, and the student’s performance is discussedr:
559
length and compared with the procedure set out in the handout. Finally, the trainer stresses the importance of svmptom repertoires, and advises the student to spend additional time revising them and studying the handout. The training session takes 45-60 minutes.
TABLE I-FIRST EXPERIMENT: ITEMS OF INFORMATION
SCORED,
BY
CATEGORY
Scoring Training
was assessed by examining the students’ written histories of the patients they interviewed on the second occasion, and comparing the trained and untrained groups for the number of relevant and accurate items of information reported. Information was defined as relevant to the students’ task if it fell into one of the 9 categories described below. The accuracy of the information was checked against the case-notes. D.R.R., working "blind", transferred all relevant information from the case-notes onto standard forms, and any item which the student reported and which appeared on the form was defined as accurate. The reports were scored blind by two members of the medical staff who were not otherwise connected with the experiment. Their task was to read the history and to score one point for every item of information which fell into one of the 9 categories and was confirmed by the transcription of the case-notes. Each scored half the histories from the trained group and half from the untrained group. No instances of inaccuracy were recorded, but, when an item was neither confirmed nor ruled out by the case-notes, the student was given the benefit of the doubt. Points were awarded as follows: (1) Symptoms.-One point for each symptom reported pres-
absent. Course of the disorder.-One point for onset dated to (2) within 1 month, and for each precipitant or absence of precipitants, each change point, and each precipitant of change. (3) Effects of symptoms on adjustment.-One point for each area reported to have been affected or not affected. (4) Other problems.-One point for each additional problem (e.g., sexual, marital, occupational) reported present or absent. (5) Treatment of current episode.-One point for each type of treatment (e.g., drug therapy, behaviour therapy) and each precise name (e.g., ’Tryptizol’, systematic desensitisation), and for dose, duration, clinical effects, side-effects, and precise dat-
N.S.=not
tant
significant.
issue. The programme consists of five components
(a scheme for history-taking; discussion of the scheme; practice under controlled conditions; video-feedback; and advice to revise symptom repertoires and the handout), and it may be that one particular component is responsible for the effect and that the remainder of the programme is redundant. For example, it may be that video-playback is all-important, or, alternatively, perhaps a student who simply reads and discusses the printed handout will perform as well as a student who undergoes the full programme. The first experiment was not designed to examine these questions, so a second experiment was conducted. SECOND EXPERIMENT
ent or
ing. (6) Previous episodes.-One point for each previous episode for establishing absence of previous episodes, and for precise dating, nature of episode, treatment, and outcome. (7) Family history.--One point for each relative reported to have suffered or not suffered from a psychiatric disorder, and for type of disorder, treatment, and outcome. (8) Previous personality.-One point for each characteristic reported. ,9) Current supports.-One point for each individual who or
pves support, and for each individual who fails to port.
Results The results
give
sup-
are
Subjects and Procedure A consecutive sample of 14 pairs of medical students took part in the experiment during their first psychiatric attachment, and all had already received a traditional training in taking histories. One member of each pair was randomly assigned to a training group, and the other was assigned to a part-training group. Each conducted two videotaped interviews which were separated by a week, and the task and instructions were identical to inose of the first experiment. The patients were again suffering from a clearly diagnosed affective disorder, and they were selected in the same way as before. This time, however, a matched-pairs design was used, so that one patient was interviewed by both members of a pair on the first occasion, and a second was interviewed by both the second occasion. The order was balanced, so that, each occasion, half the patients first met the student who was assigned to the training group, and half met the other student first. Having written up the patient’s history at the end of the first interview, each student underwent his training, which was again given by G.P.M. One week later, all 28 students returned for their second interviews, and once they had written up the history, they were debriefed.
on on
analysed by the Mann-Whitney u in test,3 given table i. In total, trained students median a of 35.5relevant and accurate items reported of information, against 13.5for the untrained group, a difference which is reflected in 5 of the 9 categories, and II highly significant (u=2; r
ing, and so make it difficult for the student to develop the holistic approach which he will need to adopt if he is to meet the needs of his patients and overcome the constraints of limited time which he will meet in real practice. It seems probable, therefore, that the history-taking skills of medical students could be much improved if these gaps in training were remedied. We suggest that this could be done as follows: by giving students a more detailed and relevant model of how to take an initial history and what questions to ask; by giving them a chance to practise this under conditions of direct observation within strict time-limits; and by providing them with feedback about their performance. Indeed, we have already put these suggestions to the test, and, as we report in the following paper" and in a recent review,12 the results have been encouraging. They indicate that much could be done of a practical nature to help medical students and doctors to improve their history-taking skills, particularly if such training were given at the beginning of their clinical course, or even
pre-clinically. 13I
This work was carried out while both authors were in the departof psychiatry, University of Oxford. D. R. R. was supported by the Mental Health Trust and Research Fund and by the Medical Research Council. We thank Prof. Michael Gelderfor his encouragement and the patients for their cooperation.
who received only traditional training. Results of the second experiment suggest that most of the programme’s effect is attributable to discussion of a printed handout which presents the student with a detailed scheme for taking histories. INTRODUCTION
preceding paper,’ we drew attention to a growing body of evidence which suggests that traditional methods of clinical training are failing to equip doctors with basic skills for taking patients’ histories. We have developed our own training programmes,2 and have tested its value in two experiments. The first tested the IN the
programme as a whole, and the second assessed the relative importance of its separate components. FIRST EXPERIMENT
The first experiment tested the hypothesis that the amount of relevant and accurate information reported at the end of a test interview would be greater for students trained by our programme than for those trained
by traditional methods.
ment
REFERENCES
1.
Hampton, J. R., Harris, M. J. G., Mitchell, J. R. A., Prichard, J. S., Seymour, C. Br. med. J. 1975, ii, 486. 2. Anderson, J., Day, J. L., Dowling, M. A. C., Pettingale, K. W. Post-Grad. med. J. 1970, 46, 606. 3. Tapia, F. Br. J. med. Educ. 1972, 6, 133. 4. Maguire, G. P., Clarke, D., Jolley, B., Unpublished. 5. Helfer, R. E. Pediatrics, Springfield, 1970, 45, 623. 6. MacNamara, M. Br. J. med. Educ. 1974, 8, 17. 7. Maguire, G. P., Julier, D. L., Hawton, K. E., Bancroft, J. H. J. Br. med. J. 1974, i, 286. 8. Korsch, B. M., Gozzi, E. K., Francis, V. Pediatrics, Springfield, 1968, 42, 855.
Maguire, G. P. in Modern Perspectives in Psychiatric Aspects of Surgery (edited by J. Howells and M. Bruner); New York (in the press). 10. Goldberg, D. P., Blackwell, B. Br. med. J. 1970, ii, 439. 11. Rutter, D. R., Maguire, G. P. Lancet, 1976, ii, 558. 12. Maguire, G. P., Rutter, D. R. in Communication between Doctors and Patients (edited by A. E., Bennett); p.45. Oxford, 1976. 13. British Medical Journal, 1976, i, 1362. 9.
HISTORY-TAKING FOR MEDICAL STUDENTS II—EVALUATION OF A TRAINING PROGRAMME
D. R. RUTTER
Department of Psychology, University of Warwick, Coventry CV4 7AL
Subjects and Procedure A consecutive sample of 24 medical students took part in the experiment during their first psychiatric attachment. All had already received a traditional training in taking histories. 12 were randomly allocated to a "training" group, and 12 to a "no-training" group, and each student conducted two videotaped interviews which were separated by a week. On each occasion, the student was set the task of spending 15 minutes with the patient and of finding out as much as he could about the current illness or problems. He was told that the patient was suffering from an affective disorder, that the interview would be videotaped, that it was his responsibility to terminate the interview on time, and that he would be asked to write up the patient’s history immediately afterwards. The patients-inpatients, day-patients, or outpatients-were suffering from clearly diagnosed affective disorders, and were selected by medical staff not otherwise connected with the experiment. Each student met a different patient on the two occasions, and each patient took part in only one interview. Having written up the patient’s history at the end of the first interview, students assigned to the no-training group were sent allay without comment, and were asked to return the following week for the second interview and not to discuss the experiment in the meantime. Those assigned to the training group remained and were given their training, individually, by G.P.M. One week later, all 24 students returned for their second interviews and, after they had written up the patient’s history, they were debriefed,
G. P. MAGUIRE
University Department of Psychiatry, University Hospital of South Manchester, West Didsbury, Manchester M20 8LR
Training Details of the
training
programme have been giver a printed handed
elsewhere.2 First, the student is given
sets out a standard, structured scheme for taking histories, and draws attention both to the informaticr
which Two experiments designed to evaluate a Summary programme for training medical students in history-taking skills were carried out. Results of the first indicate that students who underwent the programme reported almost three times as much relevant and accurate information after a test interview as those
which should be obtained and to the techniques v.h). should be used. He reads the handout carefully and d.i cusses it with the trainer. Next, his interview is reptaBei The recording can be stopped and replayed again at jr point, and the student’s performance is discussedr:
559
length and compared with the procedure set out in the handout. Finally, the trainer stresses the importance of svmptom repertoires, and advises the student to spend additional time revising them and studying the handout. The training session takes 45-60 minutes.
TABLE I-FIRST EXPERIMENT: ITEMS OF INFORMATION
SCORED,
BY
CATEGORY
Scoring Training
was assessed by examining the students’ written histories of the patients they interviewed on the second occasion, and comparing the trained and untrained groups for the number of relevant and accurate items of information reported. Information was defined as relevant to the students’ task if it fell into one of the 9 categories described below. The accuracy of the information was checked against the case-notes. D.R.R., working "blind", transferred all relevant information from the case-notes onto standard forms, and any item which the student reported and which appeared on the form was defined as accurate. The reports were scored blind by two members of the medical staff who were not otherwise connected with the experiment. Their task was to read the history and to score one point for every item of information which fell into one of the 9 categories and was confirmed by the transcription of the case-notes. Each scored half the histories from the trained group and half from the untrained group. No instances of inaccuracy were recorded, but, when an item was neither confirmed nor ruled out by the case-notes, the student was given the benefit of the doubt. Points were awarded as follows: (1) Symptoms.-One point for each symptom reported pres-
absent. Course of the disorder.-One point for onset dated to (2) within 1 month, and for each precipitant or absence of precipitants, each change point, and each precipitant of change. (3) Effects of symptoms on adjustment.-One point for each area reported to have been affected or not affected. (4) Other problems.-One point for each additional problem (e.g., sexual, marital, occupational) reported present or absent. (5) Treatment of current episode.-One point for each type of treatment (e.g., drug therapy, behaviour therapy) and each precise name (e.g., ’Tryptizol’, systematic desensitisation), and for dose, duration, clinical effects, side-effects, and precise dat-
N.S.=not
tant
significant.
issue. The programme consists of five components
(a scheme for history-taking; discussion of the scheme; practice under controlled conditions; video-feedback; and advice to revise symptom repertoires and the handout), and it may be that one particular component is responsible for the effect and that the remainder of the programme is redundant. For example, it may be that video-playback is all-important, or, alternatively, perhaps a student who simply reads and discusses the printed handout will perform as well as a student who undergoes the full programme. The first experiment was not designed to examine these questions, so a second experiment was conducted. SECOND EXPERIMENT
ent or
ing. (6) Previous episodes.-One point for each previous episode for establishing absence of previous episodes, and for precise dating, nature of episode, treatment, and outcome. (7) Family history.--One point for each relative reported to have suffered or not suffered from a psychiatric disorder, and for type of disorder, treatment, and outcome. (8) Previous personality.-One point for each characteristic reported. ,9) Current supports.-One point for each individual who or
pves support, and for each individual who fails to port.
Results The results
give
sup-
are
Subjects and Procedure A consecutive sample of 14 pairs of medical students took part in the experiment during their first psychiatric attachment, and all had already received a traditional training in taking histories. One member of each pair was randomly assigned to a training group, and the other was assigned to a part-training group. Each conducted two videotaped interviews which were separated by a week, and the task and instructions were identical to inose of the first experiment. The patients were again suffering from a clearly diagnosed affective disorder, and they were selected in the same way as before. This time, however, a matched-pairs design was used, so that one patient was interviewed by both members of a pair on the first occasion, and a second was interviewed by both the second occasion. The order was balanced, so that, each occasion, half the patients first met the student who was assigned to the training group, and half met the other student first. Having written up the patient’s history at the end of the first interview, each student underwent his training, which was again given by G.P.M. One week later, all 28 students returned for their second interviews, and once they had written up the history, they were debriefed.
on on
analysed by the Mann-Whitney u in test,3 given table i. In total, trained students median a of 35.5relevant and accurate items reported of information, against 13.5for the untrained group, a difference which is reflected in 5 of the 9 categories, and II highly significant (u=2; r
